The nurse is caring for the client in the intensive care unit immediately after removal of the endotracheal tube. Which of the following nursing actions is most important to complete every hour to ensure that the respiratory system is not compromised?

Monitor heart rhythm.

Auscultate lung sounds.

Assess capillary refill.

Obtain vital signs.

Answer and Explanation

The Correct Answer is B

A. Monitor heart rhythm: While cardiac monitoring is important, it doesn’t directly assess airway status or ventilation. Respiratory compromise must be identified through airway-focused assessments.
B. Auscultate lung sounds: Hourly lung auscultation helps detect early signs of airway obstruction, stridor, or atelectasis. It’s the most direct way to monitor for post-extubation respiratory issues.
C. Assess capillary refill: Capillary refill assesses peripheral perfusion but gives little information about airway patency or breathing effectiveness after extubation.
D. Obtain vital signs: Vital signs are useful but may not change until respiratory compromise becomes severe. Lung assessment provides earlier clues of deterioration.

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Correct Answer is B

Explanation

A. Eating alone so the client can eat at his own pace and not be hurried: While avoiding pressure during meals can help, eating alone may contribute to social isolation and decrease interest in food. Mealtime companionship often encourages intake and comfort.
B. Preparing cool or cold foods that may be better tolerated: Cool or cold foods often have less odor and are easier to tolerate, especially for clients with nausea or decreased appetite. This can reduce sensory overload and make eating more pleasant.
C. Providing several choices on the plate so that the client has what may appeal to him: Too many options at once can be overwhelming and reduce appetite in some clients. Simpler, smaller servings may be more effective than offering multiple foods at once.
D. Offering high caloric foods to build fat and muscle: While calorie-dense foods are useful, the primary goal in end-of-life care is comfort and appetite stimulation, not rebuilding muscle. Forcing high-calorie intake can lead to resistance or nausea.

A. "Chest pain should always be evaluated." B. "But you are okay now." C. "It must have been frightening for you." D. "We would not let you die."

Correct Answer is C

Explanation

A. "Chest pain should always be evaluated.": While true, this response shifts focus away from the client’s emotional experience. It is more clinical than empathetic, and may not validate the client's current distress.
B. "But you are okay now.": This can feel dismissive of the intense fear the client experienced. While intended to reassure, it overlooks the need for emotional validation during recovery from a panic attack.
C. "It must have been frightening for you.": This statement acknowledges and validates the client’s emotional experience. Empathic reflection helps reduce shame and fosters therapeutic rapport during an anxiety crisis.
D. "We would not let you die.": This response may sound comforting but unintentionally minimizes the client’s perceived fear and lacks therapeutic depth. It doesn’t address the emotional intensity of the situation.

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The nurse is caring for the client in the intensive care unit immediately after removal of the endotracheal tube. Which of the following nursing actions is most important to complete every hour to ensure that the respiratory system is not compromised?

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Correct Answer is B

Explanation

Correct Answer is C

Explanation

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